Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario

Inevitably, the delivery of healthcare in conflict means not everything goes the way you would like or had planned, even when you have tried to do everything right. How do you manage a sense of failure eg. a patient death or a missed diagnosis?

• List the Issues that arise from the scenario

The intention to optimize quality of care given to patients can come at sacrifice of a doctor’s mental health. It can lead to difficulty of doctor forgiving themselves and acknowledging that they have limited capabilities.

A doctor’s intention to improve quality of care by being honest to themselves about shortcomings in their performance is not reciprocated in culture of medical team. There could be aspects to do with the culture of the team that he/she is working in that makes it difficult to improve (for example a blame culture)

• Identify Critical Information required and Assumptions to be made

Step 2 – ANALYSE

Patient: What are the views of the Patient? (and ‘patient group’)? How do 4 principles of : Autonomy, Beneficence, Non-maleficence and Justice apply? Other perspectives?

Autonomy - patients have a right to know about mistakes that doctors have made that have impacted expected clinical outcome.

Beneficence - doctors admitting mistakes to patients can promote trust between the patient and the doctor.

Clinical: What are the clinical diagnosis, prognosis, treatment options? Is this scenario covered by professional regulation or guidance? What are the views of individual members of the clinical team? Other perspectives?

Ethical Principles: WMA Declaration on Guidelines for Continuous Quality Improvement in Healthcare at

https://www.wma.net/policies-post/wma-declaration-on-guidlines-for-continuous-quality-imrpovement-in-health-care

Healthcare in Danger

https://shop.icrc.org/health-care-in-danger-the-responsibilities-of-health-care-personnel-working-in-armed-conflicts-and-other-emergencies-pdf-en

• What can the doctor do to learn from the experience?

Doctor should decide for themselves what is appropriate standard of care. Appropriate standard of care is defined in this document to be using ‘appropriate materials and technology’ and ‘the application by the health-care worker of professional knowledge and expertise’ within ‘a relationship of trust’.

So for example, the majority of surgeons working in the military will not have dealt with a ballistic fracture in real time prior to deployment. In developed countries, the standard would be to refer to a orthopedic surgeon for specialist treatment like internal fixation. The resources (equipment, aseptic environment) or in terms of expertise might not be there in times of armed conflict. In this case, the surgeon would then provide care based on general surgical principles.

Doctors can also evaluate clinical outcomes in their own practice as outlined in the document such as for people with lower-limb fractures, the number of days in hospital or for people with open wounds, the number of operations per patient.

Ways that a doctor can measure clinical outcomes for a whole clinical team include overall hospital mortality rate for a given condition and mortality rate for those who have had an operation.

There are indications when appropriate standards of care have been neglected. Examples include when there is no admission register or when there is no provision of 24-hour care.

Doctors should disclose to patients mistakes that have affected their expected clinical outcome. This helps relieves guilt from doctor and also makes it more likely that doctor will engage in learning process of what could be done next time to help mitigate the mistake.

Doctors should ensure that they are doing things that maintain their wellness (sleep, diet and exercise)

• How can the clinical team help?

Giving support in forms of counselling.

https://www.sciencedirect.com/science/article/pii/S0736467917311678?via%3Dihub

Suffering in Silence: Medical Error and its Impact on Health Care Providers

This article discusses the majority of healthcare error is error in system or team as opposed to individual error. It bring to light the importance of system review of performance.

There should be regular review of a team’s performance.

Perspective from members form clinical team should be supportive. They should acknowledge and be honest with the mistake that has been made. And if the doctor needs it, help him or her with figuring out next steps to learning from the mistake.

Legal: Is scenario covered by IHL, Geneva Conventions, military law, other law? Other perspectives?

Geneva Conventions not applicable.

Societal/Military: Is there a military necessity? Is this scenario covered by military regulation or military perspective? Is this scenario covered by public health or societal ethics? Other perspectives?

https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors/leadership-and-management-for-all-doctors/maintaining-and-improving-standards-of-care

GMC: Maintaining and Improving Standards of Care

1. You should regularly reflect on your own performance, your professional values and your contribution to any teams in which you work. You should ask for, and be prepared to act on, feedback from colleagues and patients, including through the outcomes of audits, appraisals and performance reviews (see paragraphs 30 - 32), and through patient complaints and comments

Step 3 – FUSE

So there are things that doctor can do themselves to decrease moral injury. This includes doing things to help maintain their wellness (sleep, diet and exercise). It includes doing things that promote self-forgiveness (being honest to patients and clinical team about their mistakes). It includes analyzing and learning from the situation (establishing what appropriate standards of care are, how to measure standards of care).

There are things that the clinical team can do to decrease moral injury amongst it’s workers. One thing is to regular reflection on their performance. This helps to promote a culture of learning and not blaming each other.

Step 4 – DECIDE

• What is your Decision?

There are things that a doctor and both the clinical team can do to decrease moral injury.

Reviewed and formatted by: Yvonne Zhou MBBS Year 3 King’s College London Dec 2024

General Medical Council (UK). Good Medical Practice. Domain 2: Safety and quality. Respond to risks to safety. At: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-2----safety-and-quality?#paragraph-28 accessed 11 Jun 2020.

Jennifer J. Robertson, Brit Long. Suffering in Silence: Medical Error and its Impact on Health Care Providers. Journal of Emergency Medicine. 2018;54(4):402-409. https://doi.org/10.1016/j.jemermed.2017.12.001.

Cathy Donaghy, Rachel Doherty, Terry Irwin. Patient safety: a culture of openness and supporting staff. Surgery (Oxford) 2018;36(9):509-514 https://doi.org/10.1016/j.mpsur.2018.07.005.